Pelvic Organ Prolapse

With age and childbirth, the muscles and ligaments which support the pelvic organs (bladder, rectum, uterus, small
intestine) can weaken, resulting in pelvic organ prolapse. Pelvic organ prolapse is essentially a hernia that develops within the pelvis, causing the fallen organ to push through the vaginal wall. Any organ can prolapse
and the terminology is based on the fallen organ:

  • Cystocele (Bladder Prolapse)
  • Rectocele (Rectal Prolapse through the vagina)
  • Enterocele (small bowel/intestine prolapse)
  • Uterine Prolapse (Uterus prolapsing)
  • Vaginal Vault Prolapse (Top of the vagina falling after hysterectomy)

What causes prolapse?

A prolapse may result from muscle straining while giving birth. Other kinds of straining-such as heavy lifting or repeated straining during bowel movements-may also cause the bladder to fall. The hormone estrogen helps keep the muscles around the vagina strong. When women go through menopause-that is, when they stop having menstrual periods-their bodies stop making estrogen, so the muscles around the vagina and bladder may grow weak.

How is prolapse diagnosed?

A doctor may be able to diagnose a grade 2 or grade 3 cystocele from a description of symptoms and from physical examination of the vagina because the fallen part of the bladder will be visible. Typical symptoms of prolapse area vaginal bulge, the sensation of sitting on something, difficult or painful intercourse, lower back discomfort, or problems with the bladder or bowel. Other tests may be needed to find or rule out problems in other parts of the urinary system.

How is prolapse treated?

Treatment options range from no treatment for a mild prolapse to surgery for a serious prolapse. If a prolapse is not bothersome, there is often no treatment necessary. If symptoms are moderately bothersome, the doctor may recommend a pessary-a device placed in the vagina to hold the bladder in place. Pessaries come in a variety of shapes and sizes to allow the doctor to find the most comfortable fit for the patient. Pessaries must be removed regularly to avoid infection or ulcers.Large prolapses may require surgery to move and keep the fallen organ in a more normal position. Dr. Ingber is considered a specialist in treating prolapse after his specialty training in Female Pelvic Medicine & Reconstructive Surgery (Urogynecology) at the Cleveland Clinic).

In patients requiring surgical treatment, there are a variety of methods, both transvaginal and transabdominal,
and with or without the use of synthetic mesh. Should you require surgery, Dr. Ingber will discuss all these
options with you so you can have the proper procedure performed.

Cystocele (Fallen Bladder)

What is a cystocele?

A cystocele occurs when the wall between a woman’s bladder and her vagina weakens and allows the bladder to droop into the vagina. This condition may cause discomfort and problems with emptying the bladder.

A bladder that has dropped from its normal position may cause two kinds of problems-unwanted urine leakage and incomplete emptying of the bladder. In some women, a fallen bladder stretches the opening into the urethra, causing urine leakage when the woman coughs, sneezes, laughs, or moves in any way that puts pressure on the bladder.

A cystocele is mild-grade 1-when the bladder droops only a short way into the vagina. With a more severe-grade 2-cystocele, the bladder sinks far enough to reach the opening of the vagina. The most advanced-grade 3-cystocele occurs when the bladder bulges out through the opening of the vagina.

What causes a cystocele?

A cystocele may result from muscle straining while giving birth. Other kinds of straining-such as heavy lifting or repeated straining during bowel movements-may also cause the bladder to fall. The hormone estrogen helps keep the muscles around the vagina strong. When women go through menopause-that is, when they stop having menstrual periods-their bodies stop making estrogen, so the muscles around the vagina and bladder may grow weak.

How is a cystocele diagnosed?

A doctor may be able to diagnose a grade 2 or grade 3 cystocele from a description of symptoms and from physical examination of the vagina because the fallen part of the bladder will be visible. A voiding cystourethrogram is a test that involves taking x rays of the bladder during urination. This x ray shows the shape of the bladder and lets the doctor see any problems that might block the normal flow of urine. Other tests may be needed to find or rule out problems in other parts of the urinary system.

How is a cystocele treated?

Treatment options range from no treatment for a mild cystocele to surgery for a serious cystocele. If a cystocele is not bothersome, the doctor may only recommend avoiding heavy lifting or straining that could cause the cystocele to worsen. If symptoms are moderately bothersome, the doctor may recommend a pessary-a device placed in the vagina to hold the bladder in place. Pessaries come in a variety of shapes and sizes to allow the doctor to find the most comfortable fit for the patient. Pessaries must be removed regularly to avoid infection or ulcers.

Large cystoceles may require surgery to move and keep the bladder in a more normal position. This operation may be performed by a gynecologist, a urologist, or a urogynecologist. The most common procedure for cystocele repair is for the surgeon to make an incision in the wall of the vagina and repair the area to tighten the layers of tissue that separate the organs, creating more support for the bladder.

Rectocele (Fallen Rectum)

A rectocele forms when the rectum bulges out into the vagina upon straining, or even at rest. Rectoceles may cause constipation symptoms, and some women have to insert fingers to push down on the bottom of the vagina to assist in having a bowel movement—this is called “Vaginal Splinting.”

Rectoceles are graded in a similar way that cystoceles are. Grade 1 rectoceles are usually asymptomatic and
typically require no therapy. Grade 2-3 Rectoceles are often more bothersome and may require repair.

Rectoceles may be treated in a similar way that cystoceles are treated—either with a pessary (foreign device
which is inserted through the vagina) or surgery. Surgery is typically done in the outpatient setting. Stitches are placed to tighten the muscles over the rectocele and restore the normal anatomy. Women can return to work relatively quickly after these procedures.

Uterine Prolapse

Uterine prolapse is when the uterus falls from its normal position within the female pelvis through the vaginal opening.

What causes Uterine Prolapse?

Muscles and ligaments hold the uterus and other pelvic structures in the normal anatomic position. With age, and after vaginal delivery, these ligaments and muscles can become weak, causing the uterus to “drop.”

How is Uterine Prolapse Treated?

Traditionally, uterine prolapse is treated with a hysterectomy (removal of the uterus), along with a procedure to
suspend, or lift, the top of the vagina (apex) back up to its normal position. Hysterectomies can be performed either through the vagina (vaginal hysterectomy) or through an abdominal approach. The latter is often done through a minimally invasive approach (laparoscopic, LESS, or da Vinci robotic) where tiny keyhole incisions are made. Instruments are then inserted through these incisions to perform the surgery.

Do I need a hysterectomy if I have uterine prolapse?

Recent studies have shown that not every woman needs a hysterectomy for prolapse. Some women feel that their uterus is a part of them and would rather not lose this organ in a surgery. Dr. Ingber was trained in minimally-invasive techniques for uterine suspension (hysteropexy). The uterus can be lifted back to its normal spot through a vaginal approach (sacrospinous hysteropexy) or through an abdominal approach (laparoscopic, da Vinci robotic, or LESS hysteropexy).